Normalizing the political economy of improving health

Abstract Problem Political economy factors are important in determining the adoption and implementation of health policies. Yet these factors are often overlooked in the development of policies that have the potential to influence health. Approach Political economy analysis provides a way to take into consideration political and social realities, whether at the community, subnational, national, regional or global levels. We aim to demonstrate the value of political economy analysis and to promote its wider use in technical programmes of work. Local setting We provide examples from across a range of World Health Organization areas of work, including participatory governance, health financing, health taxes, malaria prevention and control, capacity-building and direct country support. Relevant changes Existing examples of how political economy analysis can be incorporated into technical support demonstrate the variability of this analytical approach, as well as its potential to support policy progress. Applying political economy analysis within the specified programmes of work has enabled more contextually relevant technical support to enhance the likelihood of advancing countries’ health-related objectives. Lessons learnt Embedding political economy into technical work has many benefits, including: enhancing voice and participation in health policies; supporting the adoption and implementation feasibility of technically sound policies; and building capacity to incorporate and understand political factors that influence health-related priorities.


Introduction
As the coronavirus disease 2019 pandemic has demonstrated, policies that impact health and well-being are not only influenced by scientific evidence, but also by the political views and underlying values of policy-makers and societies. 1 The need to make policy decisions in the face of uncertainties and incomplete information complicates these influences. Given the inextricable link between politics and public health, approaches are needed to systematically assess, analyse and incorporate the two factors as part of efforts to improve health.
Throughout this article we aim to demonstrate the value of political economy analysis in technical programmes of work to improve health and well-being. Analysing political economy provides a way to respond to and take into consideration the political, economic and social forces that impact health and related policies, whether at the community, subnational, national, regional or global levels.

Approach
Politics has been described as "who gets what, when, and how. " 2 If we apply this concept to health then any number of inputs, variables and factors influence the distribution of health resources and services. As technical advisors working for the World Health Organization (WHO) we are often faced with considerations around the political dimensions of health and related reforms. Political economy analysis (Box 1) grounds our technical work in a structured assessment of the politics and economics of a given context. 3 By applying this method, we recognize the role of politics, social values, economics and institutions in shaping policy decisions that impact health.
We outline some recent examples of how we have incorporated political economy analysis into the many aspects of WHO's technical work. The examples, which are not intended to be a complete or representative selection of our work, can be grouped into three themes. The first theme is efforts around enhancing people's voice and participation in policyand decision-making. Participatory governance is core to the values embedded within universal health coverage (UHC), including accountability, inclusivity, responsiveness and people-centredness. How these participatory approaches are established and managed is inherently political and directly impacts policy. However, countries' capacity to convene different interest groups and to mediate and deal with conflicts of interests and power imbalances within a participatory programme is often weak.
The second theme is making it more feasible for technically sound policies to be adopted and implemented. This theme includes health financing reforms that promote progress towards UHC. These reforms are highly political through their impact on the distribution of entitlements, responsibilities and resources across the health sector and beyond. Another policy area is health taxes, which are a key tool to generate public resources and promote improved public health. 4 Yet emerging evidence suggests that how these taxes are developed and framed often determines their ability to achieve the intended revenue and health objectives. 5,6 Finally, although gains in health can be made through technical solutions, the threats Lessons from the field Normalizing the political economy of improving health Susan P Sparkes et al.
to durable progress are often rooted in the social, political and economic determinants of health.
The third theme is capacity-building to support Member States to embed political economy analysis into policy processes. In addition to incorporating political economy analysis within specific technical areas of work, there are efforts underway within WHO to systemize and embed these approaches into our overall support mechanisms to countries. By incorporating political economy analysis and approaches into strategic policy discussions, WHO country offices can take account of country contexts, improve technical advice related to health-system transformation, and link country partners with related global health initiatives. Beyond direct support to Member States, making political economy analysis a routine part of efforts to improve health requires adequate capacities within all countries, beyond WHO country offices, to carry out such analysis.

Local setting
We provide specific examples from across a range of WHO programmes of work that explicitly incorporate political economy analysis. The examples cover participatory governance, health financing, health taxes, combatting malaria, capacity-building and direct country support. We chose the examples to illustrate the wide range of ways to apply political economy analysis to work aimed at improving health and well-being for all.

Relevant changes
Existing examples of how political economy analysis can be incorporated into technical support demonstrate the variability of this analytical approach, as well as its potential to support policy progress. This analytical approach helps us to adapt technical work to each individual context to support advances in health-related objectives that are feasible to implement.

Participatory governance
In 2021, WHO published the Handbook on social participation for universal health coverage. 7 Developed in collaboration with civil society groups, the handbook aims to improve participatory approaches towards UHC, to provide best practice guidance, and to gather and generate evidence. Acknowledging inherently unequal power relationships among individuals and groups in participatory governance, the handbook describes a process which guides participant selection and representativeness; highlights facilitation techniques to raise the voices of citizens with less influence and power; and recommends explicitly identifying groups within society that are not participating.

Health financing reform
Given that many health financing reforms fail because of political constraints, WHO's health financing team launched a programme of work on the political economy of health financing reform in 2019. 8 The programme brings together the technical and the political aspects of health financing into a coherent process, rather than two separate streams that might diverge at some point. Building on countries' experiences and expertise, our analysis underscores the value of explicitly incorporating stakeholder interests and relative power into health financing reform strategies. 9

Health taxes
Political challenges in implementing health taxes can limit their usefulness. Indeed, more rigorous exploration of political economy factors and an understanding that how health taxes are framed can shape their implementation is needed. 10 To help rectify this, in 2021 the Alliance for Health Policy and Systems Research, a WHO-hosted partnership, launched a programme of work to identify and build the capacity of local health researchers, as a way to support policy-makers in communicating and advancing health taxes.

Political commitment
Despite impressive achievements in reducing malaria morbidity and mortality over the past 20 years, 11 there has been limited progress since 2015. The High Burden to High Impact approach, launched by WHO and the Roll Back Malaria Partnership to End Malaria in 2018, 12 is a country-led approach to get back on track to achieve the goals of WHO's Global Technical Strategy for Malaria 2016-2030. Increasing political commitment to combat malaria is one of the four response elements of the approach. By analysing their political context, countries with a high burden of malaria are developing locally appropriate strategies that are embedded in, and supported through, strong and equitable health systems.

Direct country support
WHO's country offices work closely with health ministries to develop country cooperation strategies, through which WHO provides technical advisory support, as well as bringing together all sectors and partners around collaborative, consensus-driven approaches at country level.
Implementing strategic documents often entails building consensus and managing conflict across a range of individuals and institutions. 13 The WHO Delivery for Impact team and knowledge hub formed in 2020 builds capacity and supports Member States in the process of implementing health policy towards measurable improvements in health. In explicitly recognizing the power dynamics involved in policy implementation, WHO's approach includes guidance on incorporating continual stakeholder analysis: a process which assesses the power and position of key individuals or groups in both health and non-health sectors. The process allows decisionmakers and others working on health reform to anticipate implementation challenges stemming from the different interests, opinions and positions of power among stakeholders and to develop strategies to mitigate the risk of failure.

Capacity-building
To build capacity to support Member States in using political economy analysis, the Alliance for Health Policy and Systems Research has developed the health policy analysis fellowship

Box 1. Definition of political economy analysis
Political economy analysis is the analysis of the interaction of political and economic processes in a society: the distribution of power and wealth between different groups and individuals, and the processes that create, sustain and transform these relationships over time.

Lessons learnt
Rigorously incorporating political economy analysis into technical work enables participatory approaches that enhance representation and balance power; improves the feasibility of adopting and implementing technically sound policies; and builds capacity to develop sensitive and balanced policy approaches (Box 2). Explicitly recognizing and managing underlying political and economic power structures strengthens the quality of our technical work. This approach can also help us to distinguish science from political and social processes, including the way in which that science is interpreted and incorporated into health policies. Each of the workstreams we outline above seeks to build capacity to systematically understand and incorporate political economy dynamics and factors into our technical work to support improved health. In the examples provided, political economy analysis does not supplant technical analysis or guidance, but rather complements it. In doing so, we hope to begin a process whereby political economy analysis can be integrated into technical analysis, policies and interventions to improve health, rather than viewed as something separate and distinct. Given the inherently political nature of public health, this process is not straightforward -whether at the global, national or subnational level.
With these examples we seek to clarify political economy analysis and encourage its use as part of technical work to advance UHC and health for all. ■

. Summary of main lessons learnt
• Political economy analysis enables participatory approaches that enhance representation and balance power dynamics. • Incorporating political economy analysis helps to improve the adoption and implementation feasibility of technically sound health policies. • Building capacity in using political economy analysis promotes the development of sensitive and balanced health policy approaches.
Lessons from the field Normalizing the political economy of improving health Susan P Sparkes et al.